As a community pharmacist I often saw patients repeatedly ordering their blue inhalers to relieve symptoms of asthma because they were scared that the brown preventer inhalers contained steroid and would make them look like body builders. This is, of course not going to happen using inhalers correctly. Oral thrush can be common if inhaler technique is poor but simple things like rinsing the mouth after use or using a spacer can help. Talk to your specialist asthma nurse if you are struggling with symptoms.

If we add in breastfeeding it is no surprise that mothers are concerned about their medication use to control asthma but without cause. Inhalers and steroids are compatible with breastfeeding. Not only that but breastfeeding helps to minimise the risk of your baby developing asthma in the future according to new research.

The symptoms of asthma being high because of very high pollen counts coupled with the risk of thunderstorms which can be a bad combination.

I hope this factsheet taken largely from Breastfeeding and Chronic Medical Conditions helps

wendy@breastfeeding-and-medication.co.uk

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2022/06/asthma-.pdf

“My asthma actually improves when feeding and I had a big decline when I weaned my 2-year-old twins. The symptoms have gone again now I’m breastfeeding my 3-month-old.”

Description

Breastfeeding protects against asthma in children up to the age of 6. Shorter duration and non-exclusivity of breastfeeding were associated with increased risks of asthma-related symptoms in pre-school children (Mukherjee 2016). Thus, mothers with asthma may be keen to breastfeed exclusively to protect their baby. In a study of 366 pregnancies, symptoms worsened in 36% of women (Schatz 1988).  Further studies by Schatz (1995) and Wendel (1996) in the United States suggest that 11–18% of pregnant women with asthma will have at least one emergency department visit for acute asthma and, of these, 62% will require hospitalisation.

Wilson et al (2022) studied 2021 mother-child dyads. Women reported the duration of any and exclusive breastfeeding and child asthma outcomes during follow-up at child aged 4 to 6 years. Outcomes included current wheeze (previous 12 months), ever asthma, current asthma (having ≥2 of current wheeze, ever asthma, medication use in past 12-24 months), and strict current asthma (ever asthma with either or both current wheeze and medication use in past 12-24 months). They showed that longer duration of exclusive breastfeeding had a protective association with child asthma.

Treatment

Asthma can be controlled during breastfeeding with:

• inhalers (short and long-acting beta 2 agonists to relieve symptoms
•  bronchodilators to prevent symptoms
• compound inhalers, 
• Prednisolone
• Leukotriene receptor antagonists. 

Beta-adrenoreceptor agonists relieve symptoms of asthma attack such as breathlessness: E.g., Salbutamol, Bambuterol , Formoterol, Salmeterol, Terbutaline.The inhalers act locally in the lungs and limited transfer into blood let alone milk –

Oral Corticosteroids : Prednisolone – limited transfer at 40mg/day, higher doses short term. Very high doses or long term wait 4 hours after administration to breastfeed (but rarely necessary in my experience)

Inhaled Corticosteroid Inhalers prevent asthma symptoms and are used when regular use of preventer inhalers is necessary: E.g., Beclometasone, Budesonide, Fluticasone, Mometasone. Inhalers  act locally in lungs and limited transfer into blood let alone milk

Leukotrine Receptor antagonists: Montelukast – relative infant dose 0.68%. Used in children so compatible with breastfeeding. However, in September 2019 the MHRA added a caution to use in children so individual mothers may need to decide for themselves if they wish to take this drug whilst breastfeeding.

“Healthcare professionals are advised to be alert for neuropsychiatric reactions, including speech impairment and obsessive-compulsive symptoms, in adults, adolescents, and children taking montelukast. The risks and benefits of continuing treatment should be evaluated if these reactions occur. Patients should be advised to read the list of neuropsychiatric reactions in the information leaflet and seek immediate medical attention if they occur.”

Zafirlukast– relative infant dose 0.7%. Absorption slowed with food. Used in children > 12 years so compatible with breastfeeding assumed.

Theophylline/ Aminophylline – prolonged half-life in neonates (babies < 6 weeks). One reported case of irritability. Avoid if possible, especially with young babies .

There are many options of inhalers and asthma specialist should be able to make symptoms changing life a rare rather than common event. Many athletes have asthma and are able to control symptoms with the right balance of medication. For some symptoms are worse with respiratory infections, for others season affects are greater e.g., moulds, pollen from different plant affecting different times of the year.

References

• Mukherjee M, Stoddart A, Gupta RP, Nwaru BI, Farr A, Heaven M, Fitzsimmons D, Bandyopadhyay A, Aftab C, Simpson CR, Lyons RA, Fischbacher C, Dibben C, Shields MD, Phillips CJ, Strachan DP, Davies GA, McKinstry B, Sheikh A, The epidemiology, healthcare and societal burden and costs of asthma in the UK and its member nations: analyses of standalone and linked national databases, BMC Medicine, 2016;14:113–128.
• Schatz M, Harden K, Forsythe A, Chilingar L, Hoffman C, Sperling W, Zeiger RS, The course of asthma during pregnancy, post-partum, and with successive pregnancies: a prospective analysis, J Allergy Clin Immunol, 1988;81:509–17.
• Schatz M, Zeiger RS, Hoffman CP, Harden K, Forsythe A, Chilingar L, Saunders B, Porreco R, Sperling W, Kagnoff M, Perinatal outcomes in the pregnancies of asthmatic women: a prospective controlled analysis, Am J Respir Crit Care Med, 1995;151:1170–4.
• Wendel PJ, Ramin SM, Barnett-Hamm C, Rowe TF, Cunningham FG, Asthma treatment in pregnancy: a randomized controlled study, Am J Obstet Gynecol, 1996;175:150–4.
• Wilson K, Gebretsadik T, Adgent MA, et al. The association between duration of breastfeeding and childhood asthma outcomes. Annals of Allergy, Asthma & Immunology. (https://www.annallergy.org/article/S1081-1206(22)00400-8/fulltext)
• https://www.sps.nhs.uk/articles/using-inhaled-or-topical-corticosteroids-during-breastfeeding/

Further information: 

Asthma UK https://www.asthma.org.uk/

Many mothers take norethisterone to delay periods before holidays or even their wedding. Others use it to stop heavy bleeding and wish to continue to breastfeed.

Norethisterone and breastfeeding factsheet

Norethisterone 5mg tablets (Primolut N®, Utovlan®) is often prescribed to delay periods. This might be requested by the breastfeeding mother for example before a holiday or a wedding. There is little information from the research databases to support the use at this dose in breastfeeding. The only references are significantly lower doses (350mcg daily) used in progesterone only contraceptives.

It is suggested in the literature that this dose of norethisterone may reduce the quantity of breastmilk. In my experience a few mothers have noticed a temporary dip in supply but with holidays and weddings a change of routine could account for such a change. There seems to be no risk to the breastfeeding baby of a short course of medication at this dose.

Studies suggest that lower doses do not affect the composition of milk (reported in LACTMed. However Hale (Medications and Mother’s Milk states that although it is believed to be secreted into breast milk in small amounts, it may reduce lactose content and reduce overall milk volume and nitrogen/protein content, resulting in lower infant weight gain, although these effects are unlikely if doses are kept low. Norethisterone is a component of progestin oral contraceptives (Eg. Micronor™ and Brevinor ™ )

BNF : Postponement of menstruation 5mg norethisterone  3 times daily starting 3 days before expected onset (menstruation occurs 2–3 days after stopping)

N.B This information is based on anecdote and not research based studies

References

• https://www.e-lactancia.org/breastfeeding/norethisterone/product/
• https://www.ncbi.nlm.nih.gov/books/NBK501291/
• Jones W Why Mother’s Medication Matters
• Jones W Breastfeeding and Medication

Although it is rare for a young woman to experience a heart attack, transient ischaemic attack or stroke, it does happen. They are usually prescribed anti-platelet drugs and until recently we found difficulty in providing information. However, this is the most up to date information which I have sourced and hope it helps anyone in this most difficult position.

pdf of factsheet Anti platelet drugs and breastfeeding factsheet

Anti-platelet drugs decrease platelet aggregation (stickiness) and may stop thrombus (clot)
formation. Clopidogrel is also used, sometimes alone or in combination with low-dose aspirin. There are unfortunately some mothers who, whilst breastfeeding, have a heart attack, transient ischaemic attack, stroke or other event that requires anti-platelet agents if only temporarily. Anti-platelets may also be given during investigation if such a condition is strongly suspected.
Aspirin dispersible 75 mg
Aspirin 75 mg acts by decreasing platelet stickiness irreversibly inhibiting aggregation. It is not used during treatment of thrombosis but may be used to after a myocardial infarction (MI), transient ischaemic attack and stroke or to decrease cardiovascular risk. It is also used to prevent recurrent miscarriage, with a past history of pre-eclampsia and other reasons in pregnancy (https://breastfeeding-and-medication.co.uk/fact-sheet/low-dose-aspirin-and-breastfeeding). Aspirin is not recommended during breastfeeding at analgesic doses of 600 mg four times a day, due to its association with Reye’s syndrome. However, use of low dose aspirin is considered acceptable. In the absence of the theoretical risk of association with Reye’s syndrome, aspirin would be a drug compatible with lactation due to its pharmacokinetic properties.

Milk Plasma ratio is 0.03-0.08, oral bio availability 50-75%, plasma protein binding 88-93%, relative infant dose 2.5% – 10.8%. There is no documented risk of association with Reye syndrome. Virtually all aspirin is metabolised 2-3 hours after dose.
Clopidogrel (Brand name: Plavix®)
Little is known about the levels of clopidogrel secreted into breastmilk but it’s likely to be a small amount (https://www.nhs.uk/medicines/clopidogrel/). Clopidogrel irreversibly modifies the platelet adenosine diphosphate (ADP) receptor. There are no human studies, but rat studies have shown passage into milk. This significance in human treatment is unknown. It’s unlikely that clopidogrel will cause any side effects in the baby. It is used with good tolerance in paediatrics, even in new-borns and infants (https://www.e-lactancia.org/breastfeeding/clopidogrel/product/)
The pharmacokinetics of clopidogrel show a low oral bio availability 50%, plasma protein binding 98%. Babies exposed to clopidogrel through their mother’s breastmilk should be monitored for rare bruising on the skin, blood in urine, vomit or stool.
Gastric irritation of aspirin and clopidogrel
Both aspirin and clopidogrel (Plavix ™) are gastro irritant so may need to be used with a proton pump inhibitor (PPI) for protection of the stomach. There has in the past been some concern over a potential interaction between clopidogrel and omeprazole and esomeprazole, with the anti-platelet effect of clopidogrel being diminished (https://www.gov.uk/drug-safety-update/clopidogrel-andproton-pump-inhibitors-interaction-updatedadvice#:~:text=Concomitant%20use%20of%20clopidogrel%20and,therapies%20would%20be%20mo
re%20suitable.) .

The Specialist Pharmacy Service suggest that this is a clinical decision but that
pantoprazole, lansoprazole and rabeprazole are suitable alternatives
(https://www.sps.nhs.uk/articles/do-proton-pump-inhibitors-reduce-the-clinical-efficacy-ofclopidogrel-2/). PPI medication is largely destroyed in the maternal gut and can be used during lactation.
Other anti-platelet drugs

• Prasugrel (Effient) No studies on the transfer of prasugrel into breastmilk are available
• Ticagrelor (Brilinta) No studies on the transfer of prasugrel into breastmilk are available
• Dipyridamole No studies on the transfer of prasugrel into breastmilk are available

References

• CKS Anti platelet treatment https://cks.nice.org.uk/topics/antiplatelettreatment/management/secondary-prevention-of-cvd/
• Elactancia https://www.e-lactancia.org/
• Finkelstein Y, Nurmohamed L, Avner M, Benson LN, Koren G. Clopidogrel use in children. J
  Pediatr. 2005 https://pubmed.ncbi.nlm.nih.gov/16291359/
• Hale Medications and Mothers Milk Online Access
• Kwok CS, Loke YK, Effects of proton pump inhibitors on platelet function in patients receiving
  clopidogrel: a systematic review, Drug Saf, 2012;35(2):127–39.
• Kwok CS, Loke YK, Inconsistencies surrounding the risk of adverse outcomes with
  concomitant use of clopidogrel and proton pump inhibitors, Expert Opin Drug Saf,
  2012;11(2):275–84.
• LactMed https://www.ncbi.nlm.nih.gov/books/NBK501922/
• LactMed Lansoprazole https://www.ncbi.nlm.nih.gov/books/NBK501283/
• LactMed Pantoprazole https://www.ncbi.nlm.nih.gov/books/NBK501280/
• LactMed Rabeprazole https://www.ncbi.nlm.nih.gov/books/NBK501282/
• Li JS, Yow E, Berezny KY, Bokesch PM, Takahashi M, Graham TP Jr, Sanders SP, Sidi D, Bonnet
  D, Ewert P, Jennings LK, Michelson AD; PICOLO Investigators. Dosing of clopidogrel for
  platelet inhibition in infants and young children: primary results of the Platelet Inhibition in
• Children On clopidogrel (PICOLO) trial. Circulation. 2008
• https://pubmed.ncbi.nlm.nih.gov/18195173/
• NHS Clopidogrel. https://www.nhs.uk/medicines/clopidogrel/
• Patient Info Antiplatelet Drugs https://patient.info/doctor/antiplatelet-drugs

Many women report lowered milk supply ( perceived or actual) and it is a cause of many contacts to breastfeeding experts and sadly a reason many mothers turn to formula when they hadnt intended. Domperidone has for a long time been recommended to help increase supply by utilsising its ability to increase prolactin. It shouldnt be used, in my opinion unless the mother has been supported to achieve regular and effective breastfeeding. It may be needed where a premature baby has been delivered and the mother has been pumping long term – many times the supply starts to dip after 2 weeks.

pdf of this information:

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2022/11/domperidone-as-a-galactogogue.pdf

I wrote a factsheet for BfN looking at all the studies on study outcomes some years ago (https://www.breastfeedingnetwork.org.uk/domperidone/ ) . This information is an update on my thoughts and in light of experience and new reports.

Some years ago I wrote a factsheet for the Breastfeeding Network on the use of domperidone as a galactagogue when the recommendations for the use of domperidone changed
https://www.breastfeedingnetwork.org.uk/domperidone/. The MHRA and EHRA recommended that domperidone be prescribed only in limited situations and at a maximum dose of 10mg three times a day for 7 days and not for breastfeeding mothers https://www.gov.uk/drug-safetyupdate/domperidone-risks-of-cardiac-side-effects.
Domperidone has long been used as a galactagogue to increase milk supply. Most of the evidence from studies lies with use to increase lactation after premature delivery but can be used later where breastfeeding got off to a difficult start such as separation of mother and baby. The research studies on domperidone and use to increase milk supply can be found in the BFN link. In my experience it had been used when adequate breastfeeding support had not been given and when feeding was not effective or frequent enough to stimulate supply. This should always be the first intervention and should be happening at every professional contact with a breastfeeding mother.
When should domperidone not be used ?
Domperidone interacts with other medication and should not be used:

• before assessment by someone skilled in breastfeeding support alongside expressing both
  breasts, at least 8-10 times in 24 hours including overnight
• where either mother or baby has any evidence of cardiac abnormalities and specifically
  arrhythmia
• where either is receiving other medications known to prolong QT interval or potent CYP3A4
  inhibitors e.g., quinolone antibiotics, ketoconazole, fluconazole, macrolide antibiotics, SSRI
  antidepressants (risk low with most commonly used ( Funk 2013) tricyclic antidepressants,
  salbutamol (https://ggcmedicines.org.uk/media/uploads/ps_extra/pse_21.pdf)
• where severe hepatic impairment has been identified in mother or baby
• where either mother or baby has high or low levels of potassium, or low levels of magnesium (https://ggcmedicines.org.uk/media/uploads/ps_extra/pse_21.pdf)

Are there adverse effects of domperidone on babies exposed through their mother’s milk? Hale data(2022) : milk plasma ratio 0.25% (<1 regarded as compatible with breastfeeding), plasma protein binding 93% leaving only 7% which can pass into milk, oral bioavailability 13-17% because of extensive first pass metabolism, relative infant dose 0.01%-0.35% (< 10% regarded as compatible with breastfeeding. Analysis of studies not complete but indicative of low risk to babies of domperidone passing to baby and would be grounds for use in breastfeeding to be reconsidered by EHRA and MHRA.

Higher doses of domperidone to increase milk supply?
Some breastfeeding experts have used significantly higher doses of domperidone to stimulate
lactation and continued use long term without reported adverse effects (Newman J, Polokova A What Doctors Don’t Know About Breastfeeding 2022)
Tapering off dose
There are no studies that provide an evidence base on how long to continue domperidone in the case of inadequate lactation (Academy of Breastfeeding Medicine (ABM) 2018 Anecdotally, some women feel that their supply cannot be maintained without the drug, while some can reduce the dose but not stop altogether. It is possible that domperidone is acting as a placebo to boost their confidence – we do not know and should admit the limitations of the research.
After a slow withdrawal from domperidone, one study found no significant increase in formula
supplementation suggesting that once sufficient milk production is established, it is maintained even without the use of domperidone (Livingston 2007).
Knoppert (2012) showed that in 3 out of 4 women who had taken domperidone for 4 weeks at full dose, 2 weeks at reducing dose, milk supply was maintained. Although gradual weaning from the drug has become standard, there is little published evidence apart from the reports and data is based on the experience of breastfeeding specialists.
Withdrawal
Drug withdrawal symptoms consisting of insomnia, anxiety, and tachycardia were reported in a woman taking 80 mg of domperidone daily for 8 months as a galactogogue who abruptly tapered the dose over 3 days (Papastergiou 2013).

Another mother (Seeman2015) took domperidone 10 mg three times daily for 10 months as a galactagogue and stopped abruptly. After discontinuation, she experienced severe insomnia, severe anxiety, severe cognitive problems and depression.

A third postpartum woman (Doyle 2018) began domperidone 90 mg daily, increasing to 160 mg daily to increase her milk supply. Because her milk supply did not improve, she stopped nursing at 14 weeks and began to taper the domperidone dosage by 10 mg every 3 to 4 days. Seven days after discontinuing domperidone, she began experiencing insomnia, rigors, severe psychomotor agitation, and panic attacks. She restarted the drug at 90 mg daily and tapered the dose by 10 mg daily each week. At a dose of 20 mg daily, the same symptoms recurred. She required sertraline, clonazepam and reinstitution of domperidone at 40 mg daily, slowly tapering the dose over 8 weeks. Three months were required to fully resolve her symptoms.

In a fourth case (Manzouri 2017), a mother took domperidone 20 mg four times daily for 9 months to stimulate breastmilk production. She stopped breastfeeding and domperidone at that time. Two weeks later, she presented with insomnia, anxiety, nausea, headaches and palpitations. The drug was restarted at a dosage of 20 mg three times daily and began to taper the daily dosage by 10 mg every week, but after one week she complained of insomnia. Tapering was reduced to 5 mg every week, but whenever she stopped the ndrug, symptoms returned. She was able to discontinue domperidone after tapering the daily dosage by 2.5 mg weekly over 10 months A fifth case (Sharma 2022) of a mother with a history of bipolar disorder and major depression developed severe anxiety, a recurrence of depression and obsessive compulsive disorder 6 days after abruptly discontinuing domperidone 120 mg daily that she was aking as a galactogogue. Three days later, she restarted domperidone 120 mg daily and tapered her daily dose by 10 mg at weekly intervals. She took no other medications. Two weeks after discontinuing domperidone, she had signs of only mild mood disorder. Hale (2022) reports an increase in calls to InfantRisk reporting problems with withdrawal after high dose and long-term use.

This should in my opinion be discussed with the mother before prescription of the medication.
References

• Academy of Breastfeeding Medicine ABM Clinical Protocol #9: Use of Galactogogues in
  Initiating or Augmenting Maternal Milk Production, Second Revision Bodribb W 2018.
  Breastfeed Med. 2018 Jun;13(5):307-314
• Asztalos EV, Kiss A, daSilva OP, Campbell-Yeo M, Ito S, Knoppert D; EMPOWER Study
  Collaborative Group. Evaluating the Effect of a 14-Day Course of Domperidone on Breast
  Milk Production: A Per-Protocol Analysis from the EMPOWER Trial. Breastfeed Med. 2019
  Mar;14(2):102-107. doi: 10.1089/bfm.2018.0175. Epub 2018 Dec 13. PMID: 30543461.
• Campbell-Yeo ML, Allen AC, Joseph KS et al. (2010) Effect of domperidone on the
  composition of preterm human breast milk. Pediatrics 125(1): e107-114.
• da Silva OP, Knoppert DC, Angelini MM et al. (2001) Effect of domperidone on milk production in mothers of premature newborns: a randomized, double-blind, placebo-controlled
  trial. CMAJ 164(1): 17-21
• da Silva OP, Knoppert DC. (2004) Domperidone for lactating women. CMAJ 171(7): 725
• Doyle M, Grossman M. Case report: domperidone use as a galactagogue resulting in
  withdrawal symptoms upon discontinuation. Arch Womens Ment Health. 2018
  Aug;21(4):461-463. doi: 10.1007/s00737-017-0796-8. Epub 2017 Oct 31. PMID: 29090362.
• Funk KA, Bostwick JR. A comparison of the risk of QT prolongation among SSRIs. Ann
  Pharmacother. 2013 Oct;47(10):1330-41)
• Grzeskowiak LE, Smithers LG, Amir LH, Grivell RM. Domperidone for increasing breast milk
  volume in mothers expressing breast milk for their preterm infants: a systematic review and
  meta-analysis. BJOG. 2018 Oct;125(11):1371-1378. doi: 10.1111/1471-0528.15177. Epub
  2018 Mar 27. PMID: 29469929.
• Grzeskowiak LE, Wlodek ME, Geddes DT. What Evidence Do We Have for Pharmaceutical
  Galactagogues in the Treatment of Lactation Insufficiency?-A Narrative Review. Nutrients.
  2019 Apr 28;11(5):974. doi: 10.3390/nu11050974. PMID: 31035376; PMCID: PMC6567188.
• Hale TW and Krutsch K Medications and Mothers Milk 2022 Springer Publications
• Ingram J, Taylor H, Churchill C, Pike A, Greenwood R, Metoclopramide or domperidone for
  increasing maternal breast milk output: a randomised controlled trial Arch Dis Child Fetal
  Neonatal Ed F2 of 5(2011). doi:10.1136/archdischild-2011-300601
• Knoppert DC, Page A, Warren J, Carr M, Angelini M, Killick D, DaSilva OP, The Effect of Two
  Different Domperidone Doses on Maternal Milk Production published online 3 May 2012 J
  Hum Lact
• Livingston V, Blaga Stancheva L, Stringer J. The effect of withdrawing domperidone on
  formula supplementation. Breastfeeding Med. 2007; 2:278, Abstract 3.

A brief introduction to the information on the safety of anti epilepsy medication during breastfeeding. It does not include full information but you can find more in my book or by emailing me.

pdf of this factsheet available:

Epilepsy and breastfeeding

It is difficult to provide all the information on anti-epileptic medication in a fact sheet. If you need more information you might like to buy my book (Breastfeeding and Medication 2018)! Or you can email me (wendy@breastfeeding-and-medication.co.uk). The information below is taken briefly from text in my book.

It is absolutely imperative that you do not stop taking your medication in order to breastfeed. Your baby needs you to be seizure free. I cannot imagine the risk to your baby in the home if you are alone, maybe at a bus stop or back driving having been well controlled.
Many of the drugs can be taken by breastfeeding mothers. There will be a caution to observe the baby for drowsiness and poor feeding with each one. If you take more than one drug that risk would increase. This doesn’t mean you can’t breastfeed just that we need to keep that information in our minds and ensure that the baby is feeding and growing. If he/she isn’t growing we may need to consider options and support.

Many mothers ask if they can time breastfeeds so that the baby gets a minimal level of drug. Once you have taken any drug for more than 3 days it reaches a steady state with little fluctuation across the 24-hour period. This is essential as we don’t want a time of the day when your medication falls below an effective level. So, there are no peaks and troughs in which to feed or avoid feeding.

Some mothers know that their seizures may be precipitated by tiredness so they need to find ways of getting as much rest as possible. This might be using some formula or another adult bringing the baby to you to feed then caring for it. If you are very tired be very careful with co-sleeping as you may lose your natural awareness of the baby ( www.basisonline.org.uk has more information)

Different people require different medication to stabilise epilepsy. This fact sheet is one I have tried to write several times. There is so much to discuss with individual mothers, this can only be an introduction. Please message me if you need more information or to discuss the facts presented very briefly here.
Anti-epilepsy medication

• Lamotrigine (Lamictal ®): watch baby for drowsiness and any strange rash. If your dose
  was increased in pregnancy you will need a blood test soon after birth and will probably
  have your dose reduced. Lamotrigine is present in milk, but limited data suggests no harmful
  effect on the infant.
• Topirimate (Topamax®):Öhman et al 2002. observed five babies at delivery and followed
  three of them through lactation. Two to three weeks after delivery two of the breastfed
  infants had detectable but unquantifiable levels of topiramate and one had an undetectable
  concentration; m/p ratios of around 0.86 were determined throughout the study period and
  no adverse events noted. Observe for sedation, poor feeding and diarrhoea.
• Levetiracetam(Keppra ®): Johannessen et al. (2005) studied eight women with maternal
  doses of levetiracetam up to 3.5 g daily, which produced low levels in milk and no adverse effects in their breastfed infants. The babies of mothers taking levetiracetam should be monitored for drowsiness and adequate weight gain.
• Vigabatrin (Sabril ®): This drug is used where control of seizures has not been achieved.
  Tran et al. (1998) studied two mother and baby pairs. He estimated the maximum amount of vigabatrin that a suckling infant would ingest in a day is 3.6% and 1% of the weight-adjusted daily dose respectively. It irreversibly inactivates gamma-aminobutyric acid (GABA) and the effect of this on neonatal brains is unknown. However, it is used directly to control infant spasms. Observe for sedation
• Carbamazepine (Tegretol ®): It reaches measurably detectable levels in infant serum but
  below the therapeutic range. The infant should be monitored for jaundice, drowsiness and adequate weight gain as sedation, poor sucking and hepatic dysfunction have been
  reported, although rarely.
• Sodium valproate (Epilim): this drug is now more rarely seen due to its known
  teratogenic effects (MHRA 2017). Low levels are found in breastmilk but theoretically it is
  recommended that the baby should be monitored for jaundice and liver damage.
• Phenytoin (Epanutin®): All studies of phenytoin show levels in breastmilk to be too low to cause difficulties for breastfed infants
  
  References
• Jones W Breastfeeding and Medication 2nd Ed 2018 . Routledge
• Veiby G, Engelsen BA, Gilhus NE, Early child development and exposure to antiepileptic
  drugs prenatally and through breastfeeding:a prospective cohort study on children of
  women with epilepsy, JAMA Neurol, 2013Nov;70(11):E1–E8.
• Ohman I, Vitols S, Luef G, Söderfeldt B, Tomson T, Topiramate kinetics during delivery,
  lactation, and in the neonate: preliminary observations, Epilepsia, 2002;43:1157–60.
• Johannessen SI, Helde G, Brodtkorb E, Levetiracetam concentrations in serum and in
  breastmilk at birth and during lactation, Epilepsia, 2005;46:775–7
• Tran A, O’Mahoney T, Rey E, Mai J, Mumford JP, Olive G, Vigabatrin: placental transfer in
  vivo and excretion into breastmilk of the enantiomers, Br J Clin Pharmacol, 1998;45:409–11
• MHRA, Valproate and Developmental Disorders: New Alert Asking for Patient Review and
  Further Consideration of Risk Minimisation Measures, MHRA, 2017, www.gov.uk/drugsafety-update/valproate-and-developmental-disorders-new-alert-asking-for-patient-reviewand-further-consideration-of-risk-minimisation-measures.
• SPS Safety in Lactation: Control of epilepsy sept 2020 https://www.sps.nhs.uk/articles/safety-in-lactation-control-of-epilepsy/

The question as to the compatibility of high dose vitamin d supplements in the breastfeeding mother is a frequently asked question. We appear to monitor levels more frequently than we did in the past but research is difficult to source. I hope this information helps.

pdf of this information.

High dose vitamin d supplement for breastfeeding mothers factsheet

There has been an unexpected increase over the past 15 years in the number of babies found to be suffering from rickets or symptoms of decreased bone mass which demonstrate poor levels of vitamin D (NICE PH11). Vitamin D deficiency is unusual in babies born at term to mothers with adequate vitamin D status. Some women enter pregnancy with low vitamin D levels. This may be due to:

•             lack of exposure to sunlight due to wearing concealing clothing for cultural reasons;

•             inadequate consumption of foods containing vitamin D e.g. oily fish;

•             Inadequate consumption of dairy (prevalent particularly in adolescent girls)

•             BMI greater than 30;

•             Women who spend a lot of time indoors or use sun creams limiting the absorption of ultraviolet (UV) light;

•             living in the northern hemisphere where levels of UV light are only sufficient to stimulate vitamin D production in the summer months; and

•             having dark skin, which prevents absorption of available UV light in the UK climate.

Babies born to mothers with low vitamin D levels may be born deficient. In turn this will be exacerbated by being breastfed as the vitamin D levels in breastmilk will be sub-optimal.

In 2016 SACN amended recommendations so that breastfed babies from birth to one year of age should be given a daily supplement containing 8.5 to 10mcg of vitamin D as a precaution and breastfeeding mothers should also take a daily Vitamin D supplement of 10 µg (400IU) per day

This in no way suggests that the breastmilk of a mother with low levels of vitamin D, does not have all the other health advantages but is a reflection of current awareness of the risk of sun damage in sunlight balanced with the UK climate and poor levels of sunshine for the majority of the year. Breastfeeding alone cannot redress the deficiency resulting from low levels in pregnancy. Vitamin D is a fat-soluble vitamin that is found in food and can also be made in the body after exposure to UV rays from the sun. Fortified foods are common sources of vitamin D but without sunshine exposure it is difficult to achieve maximal intake. Supplements can be taken as part of multi-vitamin products or with calcium.

Sources of vitamin D

•             More than 90% of mankind’s vitamin D supply is derived from UVB sunlight exposure

•             Oily fish including trout, salmon, mackerel, herring, sardines, anchovies, pilchards and fresh tuna

•             Cod liver oil and other fish oils

•             Egg yolk – 0.5 µg (20 IU) per yolk

•             Mushrooms

•             Supplemented breakfast cereals, mainly supermarket ‘own brands’ in the UK. Typically contain between 2 and 8 µg (80-320 IU) per 100 g

•             Margarine

In a fair-skinned individual, exposure of the face and forearms to 20–30 minutes of sunlight at midday is estimated to generate the equivalent of 2000 IU vitamin D. Between April and October all of Scandinavia, much of western Europe, including 90% of the UK (roughly north of Birmingham) and 50% of USA is above the latitude where exposure to sufficient UVB is possible (Pearce 2010).

High dose vitamin d supplements

Many breastfeeding mothers appear to be being diagnosed as vitamin D deficient and prescribed high doses daily or weekly. Hollis et al 2015 reported that “Maternal vitamin D supplementation with 6400 IU/day safely supplies breast milk with adequate vitamin D to satisfy her nursing infant’s requirement and offers an alternate strategy to direct infant supplementation. With the use of higher dose supplements the mother should observe the baby for signs of hyper calcaemia (nausea, vomiting, weight loss, thirst, muscle weakness and confusion) and if observed blood test the baby.

Hollis and Wagner (2004) studied 18 women exclusively breastfeeding one month after delivery, and gave half 1600 IU vitamin D2 and 400 IU vitamin D3 and the others 3600 IU vitamin D2 and 400 IU vitamin D for 3 months. Blood, urine, and milk samples were obtained from the mothers at months 1, 2, 3, and 4 of lactation. Infant blood was collected at months 1 and 4 (beginning and end of the study). Maternal blood was monitored for total calcium, vitamin D2, vitamin D3, 25(OH)D2, and 25(OH)D3 concentrations. Infant serum was monitored for vitamin D2, vitamin D3, 25(OH)D2, 25(OH)D3, calcium, and phosphorus concentrations. The conclusion of the study was that the 400iu per day has been recommended arbitrarily and needs further research. In the study maternal vitamin D intakes of ≥4000 IU/d appear to be safe and to provide sufficient vitamin D to ensure adequate nutritional vitamin D status for both mothers and nursing infants.

• Hollis BW, Wagner CL, Vitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant, Am J Clin Nutr, 2004;80(6 Suppl.):1752S–8S. (https://academic.oup.com/ajcn/article/80/6/1752S/4690524)

Hollis et al (2015) randomised 3 groups of exclusively breastfeeding women to 400 IU vitamin D3 per day 2400 IU or 6400 IU vitamin D3 per day, The infants of the mothers in group one were given a vitamin d supplement but those in the higher dose groups received placebo drops. 148 mothers completed the full study still exclusively breastfeeding. The conclusion of the study was that maternal vitamin D supplementation with 6400 IU/day safely supplies breast milk with adequate vitamin D to satisfy her nursing infant’s requirement and offers an alternate strategy to direct infant supplementation. This was not achieved with lower doses.

• Hollis BW, Wagner CL, Howard CR, Ebeling M, Shary JR, Smith PG,Taylor SN,  Morella K, Lawrence RA,Hulsey TC, Maternal Versus Infant Vitamin D Supplementation During Lactation: A Randomized Controlled Trial. Pediatrics 2015;136 (4): 625-634 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4586731/pdf/peds.2015-1669.pdf

Some mothers are prescribed 20,000 or 40,000 units once weekly which approximate to a similar dosage. There is limited research to support this level being compatible with breastfeeding so the baby should be monitored for hypercalcaemia as described above – nausea, vomiting, weight loss, thirst, muscle weakness and confusion

See also https://www.ncbi.nlm.nih.gov/books/NBK500914/

For full references see Breastfeeding and Medication 2018

I’m seeing increasing numbers of questions form mums in the perimenopause who are still breastfeeding. Maybe they delivered later or maybe they have been feeding to term or maybe lots of other reasons. I remember asking for blood tests to check my hormone levels because I just couldnt think clearly anymore and my memory was poor which wasnt ideal as I was just becoming an independent pharmacist prescriber! My levels had indeed dropped and I went on to HRT. This may not be everyone’s choice or be suitable for them

I have spent many hours this year looking for guideance on HRT and breastfeeding and failed to find any studies or conclusive data. Everything is anecdotal at the moment but I hope this information helps.

As usual please message me on wendy@breastfeeding-and-medication.co.uk if you have a question

PDF of factsheet available:

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/07/the-menopause-and-breastfeeding.pdf

The Menopause And Breastfeeding

There remains no conclusive research on the passage of HRT medication into breastmilk. It appears anecdotally that there is less impact from using transdermal preparations than oral medication. There remains the possibility of reduction in lactation due to the oestrogen contact inhibiting prolactin. Anecdotally HRT has been used by breastfeeding women without impact on the nursling or supply. The decision should be that of the lactating mother after discussion with her healthcare professional.

For use of vaginal oestrogen see https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-oestrogen-cream-or-pessary

I typed “menopause and breastfeeding” into a well-known search engine and what came up first was “It is most likely that you are suffering from menopausal-like symptoms due to breastfeeding. After childbirth and during breastfeeding, women’s oestrogen levels can drop to lower levels than usual. These low levels of oestrogen can cause symptoms that mimic menopause.”

Whilst in a paper published in 2020 Langton et al found that after studying 100,000 women ages 25 to 42 years in the Nurses’ Health Study II (an analysis funded by the National Institutes of Health) “Women who breastfed their infants exclusively for seven to 12 months may have a significantly lower risk of early menopause than their peers who breastfed their infants for less than a month”.  The study also suggests that pregnancy can reduce the risk of early menopause.”

As many women now give birth later than in the past, due to changes in work and finance, and feed until they and their nursling choose to stop, questions that I have received from mothers exhibiting signs of early menopause have increased substantially. Most women begin the menopause between 45 and 55 years of age.

There is also a group who have experienced premature ovarian failure which may be hereditary. There is a further group who have had their uterus and ovaries removed surgically for a variety of reasons.

Premature ovarian insufficiency (POI)

This affects about one in a hundred women under 40 in the UK. It occurs when the ovaries no longer produce normal amounts of estrogen and therefore may not produce eggs. This means that periods will become irregular or stop altogether, with symptoms of the menopause. Many women have POI without actually realising it. Any mother under the age of 40 and having irregular periods (or if they have even stopped completely) should be talk to their doctor about having further tests. No woman is too young to be menopausal. Unlike the normal menopause when the ovaries stop working completely, in POI ovarian function can be intermittent, occasionally resulting in a period, ovulation or even pregnancy. This intermittent return of ovarian function means that 5–10% of women with POI will conceive spontaneously.

Perimenopause

The period leading up to the menopause, when hormone production decreases symptoms may start to be experienced is defined as the perimenopause. The period is rather ill defined and may vary dramatically between women. It usually suggested as beginning with irregular menstruation. There may be changes to flow with periods becoming heavier or lighter. For others it may be defined by mood swings or changes in mental function. Each person has a different awareness of their own bodies. This is the period in which most calls about breastfeeding appear to originate with a request to begin hormone replacement therapy.

Menopause

The menopause is defined as an absence of menstruation for over a year. Not all symptoms will be experienced by all women, we are all different.

Typical menopausal symptoms, include:

• hot flushes
• night sweats
• vaginal dryness and discomfort during sex
• difficulty sleeping
• low mood or anxiety
• reduced sex drive (libido)
• problems with memory and concentration

However, Newson diagram shows that the menopause may affect any part of the body with a wide variety of symptoms

Reproduced from Newson, Menopause: All you need to know in one concise manual

Interestingly when Newson surveyed approximately 2,920 women about their experiences of care around the menopause. The majority of respondents had visited their usual GP:

• 66% said they were offered antidepressants rather than HRT
• 20% said they had been referred to a hospital for appointments and/or investigations e.g., migraine clinics, scans or heart tests with symptoms likely to be related to their perimenopause/menopause.

This suggests that medical understanding of perimenopausal symptoms may be poorly understood and probably more so if the women is breastfeeding as well, particularly outside of the perceived “normal” timeframe.

Post menopause

This is defined as the remainder of a women’s life which can present with an increased risk of osteoporosis although the risk is lowered in women who have breastfed (https://www.unicef.org.uk/babyfriendly/news-and-research/baby-friendly-research/maternal-health-research/maternal-health-research-bone-density/).

HRT and Breastfeeding

HRT contains oestrogen and sometimes a progesterone e.g., norethisterone, not that dissimilar to that in the combined oral contraceptive which can be used in breastfeeding. The ethinylestradiol content of COCs range from 20–40 micrograms whilst that in HRT products contain 1 – 4 milligrams of estradiol (there are 1000 micrograms in a milligram).

However, Hale says “Although small amounts of Conjugated estrogens may pass into breastmilk, the effects of estrogens on the infant appear minimal. Early postpartum use of estrogens may reduce volume of milk produced and the protein content, but it is variable and depends on dose and the individual.”

“Conjugated estrogens comprise more than 90% of the total estrogen content of human milk and plasma (McGarrigle) Estriol glucosiduronates were the predominant oestrogen metabolites (63%) in plasma”

His conclusion is that low levels pass into milk confirmed in a query to the InfantRisk forum (https://www.infantrisk.com/forum/forum/medications-and-breastfeeding-mothers/medications-and-mothers-milk/339-hormone-replacement-therapy )

Martindale (39^th Ed) states that estradiol has been detected in breastmilk after the use of pessaries containing estradiol 50 or 100mg (Nilsson 1978) and that the American Academy of Pediatrics (2001) considers that it is compatible with breastfeeding

Pharmacokinetics of HRT (Taken from Hale)

Conjugated estrogens:  Milk plasma ratio 0.08, Plasma Protein Binding 98%

References

• American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001 Sep;108(3):776-89.
• Chollet, J. A., G. Carter, et al. (2009). “Efficacy and safety of vaginal estriol and progesterone in postmenopausal women with atrophic vaginitis.” Menopause 16(5): 978-983.
• Hale TW Medications and Mothers Milk online access
• Langton CR, Whitcomb BW, Purdue-Smithe AC, et al. Association of Parity and Breastfeeding With Risk of Early Natural Menopause. JAMA Netw Open. 2020;3(1): e1919615)
• Martindale The Complete Drug Reference 39 Ed. Pharmaceutical Press
• McGarrigle HH, Lachelin GC. Oestrone, oestradiol and oestriol glucosiduronates and sulphates in human puerperal plasma and milk. J Steroid Biochem. 1983May;18(5):607-11.
• Newson, Dr Louise. Menopause: All you need to know in one concise manual. Kindle
• Nilsson S, Nygren KG, Johansson ED. Transfer of estradiol to human milk. Am J Obstet Gynecol. 1978 Nov 15;132(6):653-7